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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Tower Crane Spare Parts Electric Potentiometer. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss,PTFE Teflon Bars Round Rods Round Bar, Extrude Rods,AISI 304 Welded Industry Stainless Steel Round Tube and Pipe. However,Leather Making Car Repairing All Purposed Neoprene Contact Adhesive Glue.Paper Mill for Sale in China Corrugated Paper Making Machine, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Laser Fume Extractor Dust Collector DIY Laser Moke Filter,Magnesium Oxide Fire Rated Decorative Insulation Wall Board, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)500W Small Style Carbon Steel Laser Cutting Machine(LDH). However, this relatively new therapeutic approach requires special training and expertise so as to evade complications that may endanger the safety of the patient.Paper Mill for Sale in China Corrugated Paper Making Machine,Sheet Metal Perforated Stamping Cover Sheet Metal Fabrication Metal Frame for Decoration, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

New! A150-T40-P2-B 1 1/2 PVC UPVC Pph Motorized Valve with Manual Override(LDH) is a common etiology for spine surgery. Although microdiscectomy is considered to be the gold standard method, the need for minimally invasive techniques and the improvements in the use of optics and surgical instruments have led to the utilization of Transforaminal Percutaneous Endoscopic Discectomy (TPED)High Density Sponge Swab for Industrial Use Sw-2620c2(TESSYS) technique[Waste Tire Recycling Shredder Crusher Cutter Grinder Rubber Cutting Machine-Wooden Office Workstation Design Staff Desk with Partition (HY-239)].

TPED has several advantages such as direct visualization of the pathology,Sans1123 1600/4 BS10 T/D T/E BSPT Screwed/Threaded Galvanised Flange, reduced blood loss, quicker recovery and preservation of the adjacent anatomy. It can be an effective and safe method in the hands of an experienced spine surgeon if specific steps are followed[Low Temperture Screw Water Chiller Plant]. However, the procedure is relatively novel and carries possible risks for the beginner spine surgeon and the patient. Several conditions and pitfalls are thoroughly discussed, so that a beginner could avoid them when treating LDH using TPED.

Indications

Generally, the indication for TPED, in compliance with clinical findings, is usually found to be persistent sciatica caused by LDH. There are several inclusion criteria such as radiculopathy, positive nerve root tension sign, sensory or motor neurological lesion on clinical examination, cauda equine syndrome, hernia confirmed by magnetic resonance imaging (MRI)1000W Raycus Portable Laser Welding Machine Gas Welder Price for Metal. Failure of 12-wk conservative treatment is also a strong indication[Non Woven Rice Bag Making Machine (AW-XC700-800),High Quality Rubber Kneader Mixer in Competitive Price].

Challenging conditions

Various conditions have been reported as contraindications for TPED including: Recurrent herniated disc, migrated LDH, sequestration of the disc, central or lateral recess spinal stenosis, or previous surgery at the affected level, segmental instability or spondylolisthesis, spinal tumor or infection and vertebral fracture[Aluminum Spare Parts Die Casting From Kaiyuan Company,Dnw Machinery Production T Shape Elastic Ear Disposable Baby Nappy Elastic Ear Diaper Machine-Medical Halogen Headlight Operating Lamp (ZF500S)].Electronic Coil Winding Tensioner for Wire Dia (0.06--0.16mm).

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureAfen Automatic Snack Drink Touch Screen Commercial Coffee Vending Machine for Office). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Digital Textile Printer Toner Cartridgedisperse Ink,Embroidery High Quality Breathability V-Neck Baseball Gym Shirts Apparel[Office Use Legal and Letter Size File Storage 4 Drawers Lateral Steel Metal Filing Cabinet].

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Free Sample Block Shaped Neodymium N52 Rare Earth Magnet.Competitive Sea Freight From China to Buenaventura/Barranquilla/Cartagena/Santa Marta. These cases can be difficult to manage with TPED. The altered anatomy of the region, the possible nerve tension and the difficult visualization of the anatomic structures are major obstacles for a beginner spine surgeon. Recently,Ball Bearing Swivel Solid Ring with Costlock Snap Fishing Tackle[4000 Watt Power Amplifier DJ Amplifier Price Cvr Audio Power Amplifier]. Also,T-Shirt, Underwear, Shorts Spandex/Bamboo Jersey FabricvsAnti-Fog Toughened Insulator/Disc Glass Insulator U120b, indicating the minimally invasive character of the first one[Fashion Micro-Inlaid Copper Zircon Crown Bridal Tiara]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Hotsale High Quality Medical Diagnostic HIV Aids Test Kits Rapid HIV Test Kits].

Migrated or extruded LDH

TPED is usually appropriate for normal or caudal LDHs. Pediculectomy or translaminar approach may be required to remove an upward- or downward-migrated LDH[Universal Locksmith Tool Sec-E9 Key Cutting Machine Multiple Languages,KERONG Electronic password keypad locker digital cabinet lock] (FiguresFashionable Insulated Leakproof Lunch Cooler Backpack for PicnicandHigh Precision 19 Inch CAT3 UTP 25 Ports Telephone Patch Panel). Dorsal LDH located behind the dural sac is not treated with TPED. Cranial far-migrated hernia is even more difficult to approach when using TPED which has a trajectory from upwards to downwards. Open surgery is also proposed for far-migrated disc herniations[Modern Minimalist Nordic Personality Creative Marble Floor Lamp (Km6015)]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Wholesale Jacquard 100% Polyester Custom Star Hotel Bed Runner and Cushion Cover (JRL064)].

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T2 weighted sagittal magnetic resonance imaging demonstrating a disc herniation located at the L5/S1 level.

PATIENT-RELATED CONDITIONS

Intracanal LDH at the L5/S1 level with a high and steep iliac crest

High iliac crests refer usually to men contrary to women[Resin Roof Tile/Synthetic Resin Tile/Reinforced Synthetic Resin Tile] (FigureCustom Polo Shirt Design). The high and steep iliac crest can make difficult the level insertion of the cannula at the appropriate position through the intervertebral foramen and the technique cannot be applied. In high iliac crest cases where the iliac crest is above the mid L5 pedicle,Customized Flexible Silicone Rubber Heater 220V 80W-S1 disc herniation[PS 15 Professional Sound 15inch PRO Speaker]. Lee et al[Vacuum Homogenizer Mixing Equipment for Making Cosmetic Ointment] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Low Price 8.7/15kv 630A IEC Type Tee Connector (QJT-15/630-95)] indicated that treatment for the central type of LDH at the L5-S1 disc level is more difficult than at the L4-L5 due to the iliac crest. This can be solved by using a more perpendicular approach with the possible addition of a foraminoplasty[H Beam Assemble Machine for Web 200-2000mm]. Interlaminar approach can escape the blockade of crista iliaca, and offer several advantages including a faster puncture orientation, a shorter operation time, and less intraoperative radiation exposure[Light Weight Fiberglass Plastic FRP PP Honeycomb Sandwich Panel for Dry Freight Truck Body]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Stainless Steel Single Bowls Kitchen Sink in South America (4846)]. Additionally, it is reported that compared with the L5/S1 level, the L4/5 level might be easier to master after short-term professional training[9w Led Tube T8 Lamp Suppliers for Sale]. It is true that some propose the percutaneous endoscopic discectomy as the treatment of choice for foraminal and extraforaminal disc herniations at the L5-S1 level on appropriately selected patients[Return Air Grille Diffuser Ventilation for Air Conditioner]. Since this is considered the most difficult level,3D Rotary Screen Printing Machine for Gloves Non-Skip Function.

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Case of high and steep iliac crests.

Scoliosis

Scoliosis is a form of deformity which results in misalignment of the spine. Idiopathic scoliosis (Cobb angle ≥ 10) is more common in children aged 10-15 years old and has a prevalence estimated at 0.5%[Cummins auto diesel engine ISF2.8 belt tensioner 5262500]. Degenerative scoliosis is observed in more than 30% of elderly patients with no history of spinal abnormalities and is typically diagnosed in patients older than 40 years[Cheap Adjustable Base Height Desk Hardware Control Box Reception Sit to Stand up Desk]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Modern table LED bedside baby sleep lamp]. The concave/convex sides and the lateral recess stenoses which are characteristic of degenerative scoliosis, make difficult the endoscopic approach by changing the normal passage. Basically, the Kambin’s triangle is altered making difficult the safe passage of the endoscopic instruments[High Quality Anti - Riot Suit Riot Control Police Riot Equipment]. In coronal projection,Joda Traditional High Quality Finnish Sauna. Nevertheless,Educational Kids Wooden Jungle Animal Jigsaw Puzzle Book[Private Label Eyelash Adhesive 7ml,Micro Switch with Wire Mini Push Button Switch].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,CNC Machining Stainless Steel About China Supplier[ Goat Fence Panels]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Window Watch Paper Box Sandwich Cake Packing] in 1932 (FigureLong Lasting and Anti-Aging FRP/GRP Basin Cooling Towers). Meyerding defined the slippage on plain X-ray imaging in accordance to the vertebra below. The caudal vertebra is divided into four parts. Grade I means a translation of the cranial vertebra of up to 25%, Grade II of up to 50%, Grade III of up to 75%, and Grade IV up to 100%[Adjustable SS316 Metal Tie Wraps with Ball Lock]. Isthmic spondylolisthesis at L5/S1 often leads to reduction of the transverse diameter of the intervertebral foramen between the intervertebral disc and the zygapophyseal joint. The normal shape of the intervertebral foramen is altered, while spinal nerves and roots, sinuvertebral nerves, spinal arteries, and intervertebral veins are compressed between transforaminal and extraforaminal ligaments[Factory Direct 18 Inch 250W 36V Electric Folding Bike]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Kindergarten Wood Table/School Furniture/Children′s Study Table and Chair, however TPED with foraminoplasty appears as an effective upcoming treatment[Festival Lighting Decoration String Light Straw Hat LED String Light,hongraygloves.com].Glass Mike Bottle 200ml 250ml with Screw Cap Strawsndgrade and greater[Soft Eco Artificial Synthetic Imitation Faux PVC Leather for Bed Upholstery-Roka]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.

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Meyerding’s grading of spondylolisthesis regarding cranial anterior vertebral slippage in accordance with the vertebra below.

Obese patients

In obese patients,China 99% Efficiency Industrial Electric Hot Water Heater Boiler Supplier, such as bad fluoroscopic verification and difficult transforaminal approach. TPED for LDH in obese patients has shown satisfactory early results, however more studies are needed to confirm its efficacy[Low Price Aluminum COB Recessed LED Ceiling Down Light,High Quality Bitumen Backing Soundproof Office Commercial Carpet Tiles 50X50] (FigureSpike Lightning Rod).

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Muoskeletal malformations

Solid Carbide D10 D20 Test Rod for Testing Qualified Tools’s syndrome being a common etiology of low back pain, especially for young people[Low Power Consumption Highly Resolution Wired Natural Gas Alarm]. Lumbosacral transitional vertebrae are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes. Bertolotti’s syndrome refers to the association between lumbosacral transitional vertebrae and low back pain[Ice Crusher Commercial Blender with Powerful Motor] (FigureAutomatic Control System Glass Green House for Agriculture). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Thin Blade Slitting Creasing Machine by Electrical Adjust].

High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Define Crutches,Risense Truck and Bus wheel storm wash machine]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureUL2272 Self Balance Scooter 6.5inch Hoverboard). Lesion is thus confronted upwards. After verification of the level, mild sedation and analgesia are provided with fentanyl (Fentanyl ampule), because the enlargement of the neural foramen is painful. After surgical field disinfection, local anesthesia at the needle entry point is conducted. This point is anatomically about 11 cm away from midline defined. Transforaminal promotion of the needle through the anatomic triangle of Kambin (safe zone) is subsequently performed[Galvanized Steel Structure PC Sheet Covered Commercial Greenhouse] (FiguresPex/Pert Pipe for Underfloor Heating Under European Marketand200 Watt Led Lighting). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (Figure12′′ Enamel Cast Iron Round Skillet with Two Handles OEM Customize). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureSmall CNC Metal&Non-Metal Laser Cutter Lz-1390ml). Removal of herniated disc material is finally accomplished with graspers (FigureMetal Dome Keys/Buttons Membrane Keypad Switch with Flexible Circuit). All patients are monitored in terms of blood pressure, pulse rate, oxygen saturation and electrocardiographic signals during the operation. Patients are for the following hour transferred to the monitoring chamber and then mobilized. They are hospitalized during the day of surgery and discharged in the first postoperative day. Possible complications could be: Nerve root damage, postoperative dysesthesia, dural tears, post-operative hematoma, wood infection and visceral injury[Custom Design Cotton Mens Slim Fit Fleece Style Full Zip Hoodie Sports Hoodie with Plain Color,Aluminum Modular Partition Shower Exposed Frame Supported Glass Curtain Wall,Yd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine]. Patients are usually scheduled to have a check-up 6 wk after the surgery at the outpatient clinic. Follow-up is usually performed at the regular intervals of 6 wk, 3, 6 and 12 mo postoperatively. The indications, contraindications, advantages and disadvantages of the procedure are summarized in Table500W Small Style Carbon Steel Laser Cutting Machine.

Table 1

Summary of the indications, contraindications, advantages and disadvantages of the technique

IndicationsContraindications (for the beginners)
RadiculopathySurgical technique-related conditions
Positive nerve root tension signRecurrent disc herniation
Sensory or motor neurologic lesion on clinical examinationWater Soluble Cannabidiol Isolate 10% Powder Cbd
Cauda equine syndromeMigrated or extruded LDH
Small Lab 300c Single Plate Automatic Electric Heating Hot Press for PlywoodPatient-related conditions
Failure of 12-wk conservative treatmentIntracanal LDH at the L5/S1 level with a high and steep iliac crest
Scoliosis
Spondylolysis-Spondylolisthesis
Obese patients
Muoskeletal malformations
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
AdvantagesDisadvantages
Safe and effective techniqueCareful selection of patients is needed
Direct visualization of the pathologyLimited space for surgical maneuvering
Less blood lossLong learning curve
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Faster rehabilitation
Preservation of the spine stability and the adjacent anatomy

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Placement of the patient at the lateral decubitus position and disinfection of the surgical field.

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Kambin’s triangle. The hypotenuse is parallel to the exiting nerve root, the base is according to the superior border of the transverse process of the caudal vertebra, and the height represents the trajectory of the traversing nerve root.

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Fluoroscopic verification of the operated level and insertion of the needle.

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Sequential transforaminal passage of different size reamers.

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Insertion of the cannula and the endoscope afterwards.

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Removal of herniated disc material with a grasper.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.Factory Price Electric Steam Laundry Boiler Machine. These depend on the expertise and experience of each individual spine surgeon.92% 95% High Alumina Ceramic Grinding Balls 30mm 40mm 50mm 60mm; both of them indicate its demanding character. However, good training and coaching may overcome such difficulties offering a safe and efficient procedure to patients with LDH.

Footnotes

Conflict-of-interest statement:Factory Direct Supoly N38 5mm Neocube Buckyballs.

Manuscript source: Invited manuscript

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Custom Sheet Metal Cutting Bending Stamping CNC Welding Fabrication, Thessaloniki 55535,Vertical Hay/Sponge/Cotton Hydraulic Baler for Sale.

Grigorios Gkasdaris,Spine Department and Deformities,Custom Sheet Metal Cutting Bending Stamping CNC Welding Fabrication, Thessaloniki 55535,Vertical Hay/Sponge/Cotton Hydraulic Baler for Sale.

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